Debate: Safety culture

Safety culture and workplace or organisational culture are often intertwined but have distinct definitions. The Health and Safety Executive describe safety culture as a sub-set of an overall workplace or organisational culture. Furthermore, the RCN describes a workplace culture as the product of the attitudes and behaviours that exist there. A safety culture, then, is the product of the attitudes towards safety issues and the way work hazards are managed. The Health Foundation describe a safety culture in health care as “one where staff have positive perceptions of psychological safety, teamwork, and leadership, and feel comfortable discussing errors. In addition, there is a ‘collective mindfulness’ about safety issues, where leadership and frontline staff take a shared responsibility for ensuring care is delivered safely.”

A fundamental requirement of a safe environment is adequate staffing levels. The RCN campaign for staffing for safe and effective care argues that legislation is a necessary requisite for ensuring there are adequate numbers of staff in any setting at any time to ensure that patients and staff are safe. This must be seen as an absolute requirement to establish a safety culture throughout organisations.

The RCN’s safe staffing campaign calls for clear legislation that ensures the right number of nurses with the right skills to ensure safe and effective patient care, in all publicly funded health and care settings across the UK. A positive safety culture would recognise the importance of staffing levels as a critical control measure that impacts significantly on individual performance and patient outcomes.

Historically, attempts to improve workplace safety concentrated on technical issues and individual human failures. Modern safety practices in high-risk industries have developed out of the analyses of major accidents (for example, Chernobyl, King’s Cross) which highlighted the role that organisational policies and procedures had in precipitating accidents.

While health and social care has been slow to adopt and adapt practices from high reliability organisations, such as nuclear power and aviation, it is now recognised that organisational values can impact and enhance risk and crisis management and safe performance.

A positive safety culture has three key elements: working practices and rules for effectively controlling hazards; a positive attitude towards risk management and compliance with the control processes; and the capacity to learn from accidents, near misses and safety performance indicators and bring about continual improvement.

An organisation can seek to enact these positive characteristics in a variety of ways. One key concern of frontline staff is how they anticipate and manage risk on a day-to-day basis, often termed situational awareness. Daily safety huddles are a tested method of embedding situation awareness and embody open communication of the current situation, including identification of the sickest patients as well as those whom staff are concerned about.

The adoption of interventions like safety huddles and other techniques is often associated with organisations which pursue a positive safety culture. However organisations are living systems that change and evolve continuously. The organisational learning that comes from safety initiatives such as these can be threatened by structural and environmental factors. Therefore organisations often find they need to expand their safety management system with ways to monitor staff and patent perceptions of safety as well as other measures and indicators of quality and safety performance.

The Health and Care (Staffing) (Scotland) Bill, as at the time of writing, is intended to directly address issues of safety and the RCN has been instrumental in lobbying for a strengthened Bill. The RCN plans to support implementation of the legislation will include elements in relation to safety culture. Within NHS Scotland, Healthcare Improvement Scotland (HIS) coordinates the Scottish Patient Safety Programme (SPSP) which is a unique national initiative that aims to improve the safety and reliability of health and social care and reduce harm, whenever care is delivered. It has a variety of work streams that coordinates campaign of activity to increase awareness of and support the provision of safe, high quality care, whatever the setting across health care in Scotland.